Rev. 10.23.19 for calendar year 2020 Page 1 of 2

Brandeis University 2021 Tufts Health Plan Comparison Chart

Note: The above is intended as a brief overview of covered services only. Please refer to the Evidence of Coverage booklet (EPO’s) or the Certificate of Insurance (PPO) for more detailed benefit information.

Terms and Conditions 1. All plans include an out of pocket maximum of $2,500 for an individual and $5,000 for a family per calendar year. All

copayments, deductibles and coinsurance (including prescription drug copayments) count towards this maximum.2. EPO Value Deductible plan benefits includes a $500 deductible for single plans and a $1,000 deductible for family

plans: includes lab work & diagnostic tests, which is paid in full after deductible is met. Day surgery & hospitaladmission includes co-payments and deductible.

3. All covered Out-of-Network PPO benefits are paid at 80% after satisfying $500 deductible for single plans and a$1,000 deductible for family plans. The PPO plan out-of-pocket maximum for out-of-network services is $2,500

Covered Services Tufts EPO Value Deductible (1) Tufts EPO Premium (1) Tufts PPO

In-Network Benefit Out-of-Network (after deductible) (3)

Annual Deductible $500 for Single (2) $1,000 for Family (2) N/A N/A $500 for Single (3)

$1,000 for Family (3)

Out of Pocket Maximum $2,500 for single (1) $5,000 for family (1)

$2,500 for single (1) $5,000 for family (1)

$2,500 for single (1) $5,000 for family (1)

$2,500 for single (1)(3) $5,000 for family (1)(3)

Emergency Care (4) (6) $100 / visit $100 / visit $100 / visit $100 / visit Outpatient Care Routine Physicals (8) Doctor Office Visits

Covered in full $25 / visit

Covered in full $25 / visit

Covered in full $25 / visit

20% coinsurance 20% coinsurance

Hospitalization Room & Board (5) Physician/Surgeon Services

$500 / admission after ded. Covered in full after ded. & copay Covered in full after ded. & copay

Covered in full Covered in full Covered in full

$500 / admission Covered in full after copay Covered in full after copay

20% coinsurance 20% coinsurance (6) 20% coinsurance

Day Surgery $250 / surgery after ded. Covered in full $250 / surgery 20% coinsurance Routine Colonoscopy (8) Covered in full Covered in full Covered in full 20% coinsurance Assisted Reproductive Technology $250 / surgery Covered in full $250 / surgery 20% coinsurance High Tech Imaging (10) $75 / visit $75 / visit $75 / visit 20% coinsurance Diagnostic Test, Lab work Covered in full after ded Covered in full Covered in full 20% coinsurance Maternity Prenatal/Postnatal Care (routine) Hospitalization

Covered in full $500 / admission after ded.

Covered in full Covered in full

Covered in full $500 / admission

20% coinsurance 20% coinsurance

Mental Health & Substance Abuse Inpatient – Non-Biological (5)

• Mental Health $500 / admission after ded. $500 / admission after ded.

Covered in full Covered in full

$500 / admission $500 / admission

20% coinsurance 20% coinsurance • Substance Abuse

Outpatient – Non-Biological • Mental Health $25 / visit

$25 / visit $25 / visit $25 / visit

$25 / visit $25 / visit

20% coinsurance 20% coinsurance • Substance Abuse

Physical Therapy (short-term physical, occupational and speech therapy)

Covered in full after ded. $25 / visit $25 / visit 20% coinsurance

Chiropractic/Acupuncture Care $25 / visit, up to 20 visits per calendar year

$25 / visit, up to 20 visits per calendar year

$25 / visit, up to 20 visits per calendar year

20% coinsurance, up to 20 visits/ calendar year

Hearing Aid Benefit

First $2,000 covered per ear every 36 months. 20% coinsurance after limit has been reached.

First $2,000 covered perear every 36 months. 20% coinsurance after limit has been reached

First $2,000 covered per ear every 36 months. 20% coinsurance after limit has been reached

First $2,000 covered per ear every 36 months. 20% coinsurance after limit has been reached

Prescription Drugs (11) (up to a 30 day supply)

$15, Tier I $30, Tier II $50, Tier III

$15, Tier I $30, Tier II $50, Tier III

$15, Tier I $30, Tier II $50, Tier III

Mail Order Rx Drugs (11) (up to a 90 day supply)

$30, Tier I $60, Tier II $150, Tier III

$30, Tier I $60, Tier II $150, Tier III

$30, Tier I $60, Tier II

$150, Tier III

Weight Management & Fitness Reimbursement (9)

$150 weight management $150 fitness reimbursement

$150 weight management & $150 fitness reimbursement

$150 weight management $150 fitness reimbursement

Rev. 10.23.19 for calendar year 2020 Page 2 of 2

individual / $5,000 family per calendar year. There is a separate out of pocket maximum on in-network services of $2,500 individual /$5,000 family per calendar year.

4. Waived if immediately admitted to the hospital. If admitted to an in-network hospital, a $500 Inpatient copaymentwould apply on both the EPO Value Deductible and PPO plans. Members would be responsible for 20% coinsurance onthe PPO plan if admitted to an out-of-network hospital.

5. A semi-private room is provided unless a private room is medically necessary.6. If you receive outpatient Emergency care at an emergency facility, you or someone acting on your behalf should call

your PCP or Tufts HP within 48 hours after receiving care. You are encouraged to contact your Primary Care Physician soyour PCP can provide or arrange for any follow-up care that you may need.

7. If you receive inpatient services which are not provided by a Network Provider, you must pre-register these services. Ifyou do not pre-register, you will be subject to a Pre-registration Penalty. Please refer to the Certificate of Insurance foradditional information.

8. Cost sharing has been removed on preventive services as follows: Routine physical exams (including most preventivescreenings), Well-Child Care, Preventive Immunizations, Preventive Pap Smears, Preventive Mammograms & RoutineColonoscopies (Colonoscopies which include any surgical removal will not be considered preventive, and will be subjectto the copay, deductible and/or coinsurance).

9. The Weight Management reimbursement (up to $150 per family per year) and the Fitness Reimbursement (up to $150per family per year) is available by submitting the applicable reimbursement form to Tufts Health Plan.

10. A maximum of two copayments apply per member per calendar year.11. Prescriptions are administered by OptumRx. BIN: 610011, PCN: IXR, Group: EDHEALTH. More information available at

www.Optumrx.com or 855-546-3439